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- APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. ) //`� Job Address 0. / City 13 Lot Size X G PM ! Owner's Name 0Zh60 7/)"fddress _ - Phone y < #76Contractor�A ��VS SAddress License No. 4y b Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION , ` SYSTEM REPAIR ❑ OTHER ❑ ,� ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.� PROP. LINE /v /rajT � � - FOUNDATION -_L "AGRICULTURE WELL—�� OTHER WELL PITS/SUMPSv INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS !1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation A Dia. of Well Casing oomestic/Private Airavel Pack ❑ Tracy Type of Casing " Specifications �) 71 Public 171Other 171Delta Depth of Grout Seal T"Ie of Grout i I Irrigation RMApprox'Depth I I Eastern Surf a Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 t Depth Filler Material (Below 50'1 I TYPE OF SEPTIC WORK: NEW INSTALLATION 11 t REPAIR/ADDITION I I DESTRUCTION I I iNo septic system permitted if public sewer is ti: i available within 200 feet.I Installation will serve: Residence_ Commercial_ Other I fJ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ; Water table depth SEPTIC TANK ❑ TypelMfg Capacity t--No. Compartments PKG. TREATMENT PLT. ❑ ' Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size _ € FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS 11 Depth Size Number t I 'SUMPS ❑ Distance to nearest: Well Foundation 'Property Line -DISPOSAL PONDS ❑ x4 i 1-hereby certify that I have prepared this application and that the work will'he done in accordance with San'Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di$trict. ` ;1 J � Home owner or licensed agent's signature certifies the following: "i certify.that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for'which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." � The appfican u r quir s. Complete drawing on rev si1e1 ide. � Signed X Title: Date: FOR DEPARTMENT USE LY # Application Accepted byi DateArea C� .i _ (✓ Pit or Grout Inspection by �'i'✓�r` 1 Date � . d Final ihspection.by � Date Additional Comments; �r 171Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca '1121-71 1 04 Tracy"835-6385 ;" `'� /)�1 P /lf� Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O: Box 2009, tk.; CA 95201 FEE INFO AMOUNT DUE, �� AMDUNT REMITTED CASH RECEIVED BY DATE PERMIT ND. vy +.EH 13.24IREV.iin51 9 EH 14-28 ` _ — - __ - -- _ _�� n p -